Many Doctor Pay Models May Not Qualify for Bonuses

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By Mindy Yochelson

March 17 — Many alternative payment models under the new Medicare doctor payment law likely won't meet the CMS's eligibility standards and won't be able to offer their participants annual bonuses and exemptions from performance scoring, an agency official said March 17.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) “creates a high bar for eligible APMs,” Patrick Conway, deputy administrator for innovation and quality at the CMS, told a House subcommittee. Many such models at the agency's innovation center and in the private sector “are not likely to meet all these requirements,” said Conway, who is also the CMS's chief medical officer and acting principal deputy administrator.

Alternative payment models (APMs) are expected to take the form of accountable care organizations, bundled payments and advanced primary care medical homes.

Sole Witness

Conway, the sole witness, spoke at a House Energy and Commerce Subcommittee on Health hearing intended to explore the Centers for Medicare & Medicaid Services' progress in implementing MACRA. The law replaced the sustainable growth rate, a formula that led to continual cuts in Part B provider payments that were overridden by Congress.

MACRA's pay system for many medical professionals is expected to center on the Merit-Based Incentive Payment System (MIPS), which will score providers based on performance starting in January 2019.

To avoid scoring and to receive 5 percent bonuses, professionals may join APMs that require them to assume financial risk. However, the law requires that the APMs use certified electronic health technology, be considered “advanced,” and put their participants “at more than nominal [financial] risk.” That threshold is expected to be revealed when the agency puts forth a proposed rule in the next few months.

‘Sophisticated Construction.'

“APMs hold great promise, but their variability and effectiveness require sophisticated construction and implementation,” Rep. Gene Green (D-Texas), the subcommittee's ranking member, said in his opening statement.

He said he wants to hear how the APMs will be “relevant to different specialties, different sizes of practices, and in line with state-based initiatives and private insurer models.”

Conway didn't go into detail about eligibility criteria but said he's asking specialty societies when he meets with them to suggest models that are appropriate to their area of expertise.

He said he expects the CMS to begin with a “reasonable set” of APMs that will grow over time.

The agency is pondering how to measure the level of financial risk for professionals who are in more than one APM, Conway said.

Another challenge is how to appropriately attribute patients to a particular doctor, he said. The agency is considering having patients identify which doctors they view as their own.

Single Performance Score

Under MIPS scoring, doctors and other Part B clinicians will receive a single composite performance score. The agency is in the process of developing a scoring methodology for MIPS based on performance in four weighted categories: quality, resource use, clinical practice improvement activities and meaningful use of certified technology, he said.

Conway told the subcommittee that providers will be allowed to customize health information technology to their individual practice needs.

Adjustment Relative to Threshold

The MIPS scoring system will give “professionals receive either a positive, negative, or neutral adjustment to their Medicare payments, depending on their performance “relative to a pre-established performance threshold,” Conway said.

MIPS cuts or additions to Medicare reimbursements will be 4 percent in 2019, 5 percent in 2020, 7 percent in 2021 and 9 percent in 2022.

“While the upward adjustments can go above these percentages, the law generally requires the overall adjustments to be budget-neutral, so the actual upward adjustments will be scaled in such a way to achieve this budget neutrality,” he said.

Technical Assistance

Physicians and other clinicians may need assistance in switching to a new value-based payment system “and we want to make sure that they have the tools they need to succeed,” Conway said.

The technical assistance in MACRA is for small practices and those in rural or medically underserved health professional shortage areas, he said. The intent is to help clinicians and practices comply with MIPS requirements and transition to become part of an APM.

The Medicare agency may put out a request for proposals to solicit regional or national networks to help professionals move to new models of care, he said.

To contact the reporter on this story: Mindy Yochelson in Washington at

To contact the editor responsible for this story: Janey Cohen at

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